Submucosal Artery Research Articles

An unexpected bronchoscopic finding possibly induced by extracorporeal membrane oxygenation: A case report of bronchial Dieulafoy disease.

Bronchial Dieulafoy disease (BDD), a rarely reported disease, comes from dilated or abnormal arteries under the bronchial mucosa. Patients with BDD are generally asymptomatic so this disease is frequently misdiagnosed. However, the submucosal arteries may dilate and rupture for various reasons, leading to recurrent respiratory tract bleeding and potentially life-threatening conditions. With the change of reversible factors such as intravascular pressure, the arteries may return to normal, allowing patients to recover to an asymptomatic state. This phenomenon has not been mentioned and concerned in previous studies, but it may have important implications for our correct understanding of this disease. A 44-year-old female was admitted to intensive care unit with recurrent malignant arrhythmias. With the assistance of VA-extracorporeal membrane oxygenation (ECMO), both her vital signs and internal environment were all gradually stabilized. However, she had been experiencing recurrent respiratory tract bleeding. While removing the bloody secretion with a fiber bronchoscopy, a congested protruding granule on the wall of the patient's left principal bronchus was found. The patient was diagnosed with BDD and the granule was thought to be an abnormal artery of BDD. For the patient's condition, we did not implement any targeted interventions with the abnormal artery. After the weaning of VA-ECMO, the patient's granule could not be found and the bleeding had also disappeared. She gradually weaned off the mechanical ventilation and was transferred to the Department of Cardiology. Then the patient was discharged after her condition stabilized. In more than half a year, the patient is in a normal physical condition. The appearance and disappearance of abnormal artery is an interesting phenomena of BDD. The change of intravascular pressure due to various causes such as VA-ECMO may be the primary factor of it.

Dieulafoy's lesion, the endovascular approach as a therapeutic option when endoscopic treatment has failed: A case report and brief review

AbstractDieulafoy's lesion is defined as a dilated submucosal artery that can cause spontaneous rupture and massive gastrointestinal bleeding. It is usually an incidental finding and is identified as a prominent linear or serpentine artery.We report the case of a 47-year-old patient who presented with a Dieulafoy's lesion located in the gastric fundus, which was repeatedly treated with clipping and endoscopic sclerosis, without resolving. She presented to the interventional radiology service for endovascular treatment, which after performing angiography confirmed active bleeding at the level of the left gastric artery and proceeded to embolize with 2 coils. This is a case where endovascular treatment proves to be an effective and decisive option for the treatment of bleeding in this type of injury.

S2591 Fatal Gastrointestinal Hemorrhage Caused by a Two cm Deep Mallory Weiss Tear

Introduction: Mallory-Weiss syndrome (MWS) is one of the common causes of acute upper gastrointestinal bleeding (UGIB). These tears occur primarily at the gastroesophageal junction. We present a case of a 45-year-old man presenting with acute bright red bloody vomiting and diagnosed with a rapid UGIB from a Deep Mallory Weiss Tear. Case Description/Methods: A 45-year-old male with unknown past medical history presented to the Emergency Department with bright red blood in the vomitus, going on for the past two days prior to admission. His hemoglobin on presentation was 9.9, INR was 1.2, and platelets were 46. The patient was alert and oriented × 2 on examination. The patient was started on Protonix intravenous drip and an Octreotide intravenous drip. The decision was made to perform an urgent upper endoscopy (EGD) for the patient. There were no previous baseline labs available for this patient. On EGD, a 2 cm bleeding Deep Mallory Weiss Tear was found with active bleeding at the Gastro-Esophageal junction visible in the retroflexion view on the cardia side of the stomach. The spurting area with a visible vessel was successfully injected with epinephrine, and four hemostatic clips were deployed. For further hemostasis, a single hemostatic spray was deployed. Bright red blood was seen in the cardia and fundus, and about 800 cc of blood was aspirated. Post-procedure, the patient was transferred to critical care unit for further care (Figure 1). Discussion: MWS accounts for 1% to 15% of the causes of upper GI bleeding in adults. The suggested theory is that when the intra-abdominal pressure suddenly and severely increases, the gastric contents rush proximally under pressure into the esophagus. This excess pressure from the gastric contents results in longitudinal mucosal tears, which may reach deep into the submucosal arteries and veins, resulting in upper GI bleeding. Treatment and management consist of performing EGD for the diagnosis and using endoscopic therapies like epinephrine injection, deploying clips, and hemostatic spray to control massive bleeding, as seen in our patient.Figure 1.: Therapeutics done for Deep Mallory Weiss Tear.

S2498 Endoscopic Treatment of a Dieulafoy’s Lesion in the Appendiceal Orifice

Introduction: A Dieulafoy’s lesion, typically a large caliber submucosal artery that erodes gastrointestinal (GI) mucosa, is a less common cause of GI bleeding. While these vascular abnormalities may occur throughout the GI tract, appendiceal Dieulafoy’s lesions are exceedingly rare, with described cases often resulting in surgical intervention. We present a case of a Dieulafoy’s lesion in the appendiceal orifice leading to massive GI bleeding which was successfully diagnosed and treated endoscopically. Case Description/Methods: A 75-year-old female with end stage renal disease, hypertension, hyperlipidemia, and heart failure with preserved ejection fraction presented with abdominal pain and rectal bleeding for 2 weeks duration. At onset, she was admitted to an outside hospital where computed tomography (CT) angiography showed aortoiliac and mesenteric atherosclerosis without evidence of large vessel occlusion. Esophagogastroduodenoscopy did not reveal a bleeding source. She reported infraumbilical abdominal pain and continued rectal bleeding and was transferred to our medical center. Upon arrival, the patient was hemodynamically stable with active rectal bleeding on exam. Laboratory analysis revealed hemoglobin of 6.9 grams per deciliter, platelet count of 101 per milliliter, blood urea nitrogen of 6.6 milligrams/deciliter (mg/dl), and creatinine of 6 mg/dl. She was treated with 3 units of packed red blood cell and a proton pump inhibitor. Colonoscopy showed a Dieulafoy’s lesion at the appendiceal orifice. Hemostasis was achieved with placement of 2 hemoclips (Figure). She was discharged 6 days after colonoscopy without recurrence of bleeding. Discussion: Only 6 cases of appendiceal Dieulafoy’s lesions have been reported in the literature and all were treated with laparoscopic appendectomy (Table 1). To our knowledge, this is the first reported case of an appendiceal Dieulafoy’s lesion that was successfully treated with endoscopic placement of hemoclips. There is no data comparing the efficacy of endoscopic intervention versus laparoscopic appendectomy in treating appendiceal Dieulafoy’s lesions; however, this case highlights that therapeutic endoscopy may be both safe and effective. Further reports are needed to inform recognition and optimal approach to appendiceal Dieulafoy’s lesions. Furthermore, in cases where hemostasis is achieved endoscopically, longer term follow-up may inform if appendectomy can be safely avoided.Figure 1.: Successful hemostasis of a Dieulafoy’s lesion at the appendiceal orifice after placement of 2 hemoclips. Table 1. - Previously reported Appendiceal Dieulafoy’s Lesions% and Outcomes Case Report Patient Clinical presentation and course Endoscopic hemostasis attempted? Management? Xue et al, 2020 21 F Massive hematochezia with lower abdominal pain and LOC* N Laparoscopic appendectomy Choi et al, 2016 72 M Hematochezia with associated mild abdominal pain and bloating sensation, previous melena from duodenal ulcer N Laparoscopic appendectomy and cecum wedge resection Johnson et al, 2014 51 M RLQ# pain, Acute appendicitis with incidental finding of Dieulafoy’s lesion on mid-distal appendiceal wall N Laparoscopic appendectomy Reynolds et al, 2013 68 M Massive hematochezia with perfusion requirement N Laparoscopic appendectomy Lee et al, 2011 22 M Severe lower GI† bleed N Laparoscopic appendectomy So et al, 1995 42 M Melena and dizziness N Laparoscopic appendectomy %In all previously reported cases, a Dieulafoy’s lesion was diagnosed using colonoscopy to visualize blood emerging from the appendiceal orifice, then subsequent resection revealing an ulcerated appendiceal mucosal lesion and microscopy and histopathology demonstrating tortuous vasculature penetrating the circumferential and longitudinal muscular wall of the appendix. Abbreviations: *Loss of consciousness, #Right lower quadrant, †Gastrointestinal.

Case report: The first description of a Dieulafoy's lesion in the gastric mucosa of a dog

An approximately 12-year-old, 31 kg, male neutered Labrador Retriever was presented to the referring hospital with an acute onset (less than 1 day) of hematemesis and melena. The dog was treated supportively for a presumptive gastric ulcer for 4 days with intravenous fluids, gastro protectants, such as pantoprazole, misoprostol, sucralfate, and barium, as well as an anti-emetic (maropitant) and analgesics (fentanyl, gabapentin, and tramadol). Throughout medical management, the dog continued to require blood transfusions approximately every 24 h. Given the poor medical response, the patient was subjected to an exploratory laparotomy. During surgery, a grossly raised, blister-like lesion on the mucosal surface of the stomach was appreciated on the lesser curvature of the stomach. A partial gastrectomy was performed, and the segment was submitted for histological evaluation. Histologically, there were multiple, tortuous, medium-caliber muscular arteries (>1.0 mm in diameter) in the submucosa. A single large-caliber artery (>0.75 mm in diameter) containing a partially occlusive thrombus extruded through the mucosa and projected on the ulcerated surface. The patient's signs were similar clinically and histopathologically to Dieulafoy's lesion in people. A Dieulafoy's lesion is a potentially life-threatening disorder that causes gastrointestinal (GI) hemorrhage. This lesion is characterized by a dilated, large-caliber, aberrant submucosal artery that erodes through the epithelium and ruptures, resulting in massive and potentially fatal hemorrhage. This lesion has never been documented previously in a dog.

Duodenal Dieulafoy lesion: a rare pathogeny of gastrointestinal bleeding in children

Dieulafoy lesion is a calibre persistent submucosal artery associated with a minuter mucosal defect. Dieulafoy lesion has been reported to account for 1-5.8% of acute nonvariceal upper gastrointestinal bleeding in adults, but it is rarely reported in children. Here we report a case of duodenal Dieulafoy lesion in a 13-year-old boy. After endoscopy and laparotomy, he still had no definite diagnosis and effective treatment. The duodenal Dieulafoy lesion was finally identified by selective angiography and was effectively treated by intravascular embolization. For unexplained upper gastrointestinal bleeding, the possibility of duodenal Dieulafoy lesion should be considered. A combination of multiple diagnosis and treatment methods can improve the success rate of diagnosis and treatment when a single test or treatment method cannot provide definitive diagnosis or effective treatment.

Dieulafoy Lesion as a Source of Bleeding: A Report of Two Clinical Cases

Summary Dieulafoy’s lesion is a rare source of gastrointestinal bleeding. It can be found anywhere in the gastrointestinal tract, but is most commonly seen in the proximal third of the stomach. It is a submucosal artery, adjacent to the mucosal surface, with no evidence of superficial ulcers. Lesions are routinely diagnosed and treated endoscopically. Their frequency is currently not well known, because as Dieulafoy lesions can be easily missed during endoscopy, and bleeding lesions are sometimes misidentified. In this article, we describe two cases of bleeding from the upper gastrointestinal tract, manifested by hematemesis and melena. Bleeding was successfully managed endoscopically by means of injection of adrenaline solution and application of an endoscopic hemoclip.

Research advances in Dieulafoy's disease of the bronchus (Review).

Dieulafoy's disease is characterized by abnormal submucosal arteries and results in acute luminal hemorrhage. Dieulafoy's lesions can also be found in the submucosa of the bronchus. Due to its low incidence rate and non-specific clinical symptoms, Dieulafoy's disease is easy to overlook, but can lead to massive bleeding and high rates of mortality. Therefore, improvements in the understanding of the disease are necessary. The awareness of the disease and associated diagnostic and treatment techniques have continued to improve, and thus, an increasing number of cases of Dieulafoy's disease of the bronchus have been reported. In the present review, 74 cases of Dieulafoy's disease are summarized. New technologies such as endobronchial ultrasound, narrow-band imaging, angiography and argon plasma treatment have been found to be increasingly applied to diagnose and treat Dieulafoy's disease of the bronchus. Therefore, the primary focus of this systematic review is to highlight advances in the diagnosis and treatment of bronchial Dieulafoy's disease.

S2355 An Unusual Presentation of a Rare Cause of Lower Gastrointestinal Bleeding: Cecal Dieulafoy’s Lesion Presenting as Melena

Introduction: Dieulafoy’s lesion is characterized as a large tortuous submucosal artery projecting through a small mucosal defect with no evidence of primary mucosal ulceration or erosion. These lesions are uncommonly identified as causes of acute gastrointestinal (GI) bleeding, accounting for only 1-2% of cases. Dieulafoy’s lesions can occur throughout the entire GI tract, most commonly occurring in the stomach (72% of cases) and rarely in the lower GI tract (5% of cases). Typically, lower GI tract Dieulafoy’s lesions present as hematochezia. We report an unusual case of a cecal Dieulafoy’s lesion that presented as melena. Case Description/Methods: A 64-year-old male with a relevant past medical history of hypertension, rheumatoid arthritis (on chronic steroids) and superior vena cava thrombosis (on anticoagulation) presented with melena. The patient denied bright red blood per rectum, or any other gastrointestinal symptoms. His vital signs were stable at the time of presentation. Physical examination was unremarkable except for melenic stool on rectal exam. Labs were significant for a hemoglobin of 7.0 g/dL (prior baseline of 12.0 g/dL), AST 67 U/L, ALT 43 U/L, ALP 219 U/L, INR 1.17, and PTT 55.3 seconds. Due to evidence of persistent bleeding, three units of packed red blood cells were transfused and a pantoprazole drip was initiated with suspicion of an upper GI source of bleed. Endoscopy was performed, which showed esophagitis with no active bleeding and gastritis. A colonoscopy was then performed which revealed a solitary Dieulafoy’s lesion in the cecum. An overlaying adherent clot was dislodged to reveal the lesion. Complete hemostasis was achieved using four hemostatic clips. Post procedural course was uncomplicated and the patient’s hemoglobin remained stable. Discussion: Our case describes a cecal Dieulafoy’s lesion that presented, unusually, as melena. There have been several reports of cecal Dieulafoy’s lesion presenting as hematochezia. To our knowledge, this is the first reported case of a cecal Dieulafoy’s lesion presenting solely as melena. We aim to add to the relatively few cases of cecal Dieulafoy’s reported, and help improve the diagnostic accuracy of these type of lesions. Without timely diagnosis and treatment, Dieulafoy’s lesions have the potential to progress to life-threatening bleeding. Thankfully, with expedient diagnosis and with modern endoscopic tools, hemostasis can be achieved in up to 90% of such cases.Figure 1.: A: Bleeding cecal Dieulafoy’s lesion B: Endoscopic clip removing adherent clot and exposing visible vessel C: Hemostasis achieved with four hemostatic clips.

Dieulafoy lesions as cause of upper gastrointestinal bleeding in a patient with portal hypertension

ABSTRACT Dieulafoy’s lesion is an abnormally large and tortuous submucosal artery that protrudes through a small mucosal defect resulting in gastrointestinal bleeding. We present a case of a 53-year-old man with a history of HIV and alcohol abuse who presented to the emergency room with hematemesis and melena. Upper endoscopy revealed an actively bleeding dieulafoy lesion, but due to uncontrolled bleeding, embolization of the left artery was necessitated. The incidence of dieulafoy lesions is about 0.3% to 6.7% within the stomach. The etiology remains uncertain but has been linked to alcoholism and antiplatelet drugs. We are emphasizing the importance of considering uncommon causes of upper gastrointestinal bleeding in patients with portal hypertension.

S2193 Splenic Artery Collaterals Masquerading as Gastric Varices: An Uncommon Cause of Massive Upper GI Bleed

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is most commonly due to peptic ulcer disease (PUD). However in patients with splenic artery thrombosis, collateral arterial vessels can develop. If these abnormal vessels erode into the stomach mucosa, massive UGIB can occur. Here we present a case of UGIB from submucosal splenic collateral arteries. CASE DESCRIPTION/METHODS: A 56 year old male with history of Factor 5 Leiden and antiphospholipid antibody syndrome (APLS) presented with melena and hematemesis. Esophagogastroduodenoscopy (EGD) showed possible gastric varices in the fundus with an area of ulceration (Figure 1). The patient’s prior history of heavy alcohol use and the presence of a nodular liver on CT scan suggested underlying cirrhosis and portal hypertension as the etiology for the gastric varices. However the patient was found to have a low hepatic venous pressure gradient (2 mmHg) and a subsequent liver biopsy did not reveal cirrhosis. The splenic vein was also noted to be patent on CT scan. Several days after admission, the patient experienced another episode of hematemesis with associated hypotension and tachycardia. CT angiogram at the time did not reveal any active bleeding, but did show a splenic artery thrombosis with several collateral vessels. Subsequent angiogram demonstrated large arterial collaterals in the gastric fundus with outflow to the spleen, bypassing the occluded splenic artery (Figure 2). These collateral vessels were embolized successfully and he had no further bleeding. DISCUSSION: This case highlights the importance of multidisciplinary patient care and careful assessment of a patient’s medical history and anatomy to accurately diagnose and treat underlying pathology. While our patient was thought to have varices on EGD, he did not have cirrhosis, splenic vein thrombosis or portal hypertension which made the diagnosis of gastric varices unlikely. However, he did have a splenic artery thrombosis due to underlying APLS which led to the formation of submucosal gastric arterial collateral vessels and UGIB. Submucosal arterial collateral vessels are a rare cause of UGIB and there are only a few cases described in the literature. They can form as a result of splenic artery thrombosis due to underlying coagulopathy, pancreatitis, abdominal trauma or congenital absence of the splenic artery. If these abnormal collateral vessels erode through the stomach mucosa, they can lead to UGIB. Treatment involves surgery (partial gastrectomy and splenectomy) or embolization.Figure 1.: Possible gastric varix in the stomach fundus with an area of ulceration seen on EGD.Figure 2.: Angiogram demonstrating large arterial collaterals in the gastric fundus with outflow to the spleen, bypassing an occluded splenic artery.

S3445 Dieulafoy’s Cecal Lesion: A Rare Cause of Lower GI Bleeding

INTRODUCTION: Dieulafoy’s lesion is a rare cause of upper GI bleeding and even a much rarer cause of cecal bleeding. It is most commonly located in the lesser curvature or proximal body of the stomach but rare occurrences in extra gastric sites have been reported. They often elude diagnosis due to their small size, normal surrounding mucosa and intermittent nature of bleeding episodes. CASE DESCRIPTION/METHODS: A 79 year old male with past medical history of CAD, Paroxysmal atrial fibrillation on long term anticoagulation with xarelto presented to the ED with complaints of dark tarry stools for 4 days. Hemoglobin level was noted to be 13.2g/dl two days prior to admission and on day of admission was noted to be 10.9gdl. Further work up revealed positive occult blood, TIBC level of 464, ferritin level of 57 and a transferrin saturation of 15. Xarelto was held and patient underwent upper and lower endoscopic assessment. Colonoscopic assessment revealed an active bleeding cecal dieulafoy’s lesion that was successfully clipped with three hemostatic clips and epinephrine infiltration to the surrounding area. Hemostasis was achieved, patient’s hemoglobin remained stable post procedure and he was subsequently discharged home after 48 hours. DISCUSSION: Dieulafoy’s lesion (DL) also known as caliber persistent artery accounts for about 1- 2 % of GI bleeding. It is a dilated aberrant submucosal artery that impinges and erodes through the muscularis mucosae. The overlying mucosa shows erosion and the surrounding mucosa appears normal. Almost two thirds of the lesions are located in the stomach along the lesser curvature. The remaining one third of lesions are extra gastric mostly involving the duodenum followed by the colon. Endoscopy is the gold standard of diagnosis but is only successful in detecting 49-70% of the lesions mostly because of the small nature of the lesions, normal surrounding mucosa and intermittent nature of hemorrhage. Repeat endoscopy is usually effective in diagnosis especially if repeated on a different occasion. Angiography is useful in diagnosis when endoscopic evaluation is unsuccessful in localizing the lesion. Treatment of DL involves a combination of epinephrine injection followed by bipolar probe coagulation, thermal coagulation or hemoclip placement. Conclusion: Dieulafoy’s lesion of the cecum, though rare, can be a cause of life-threatening lower GI bleeding and can easily be diagnosed and treated during endoscopic assessment.Figure 1.: An actively bleeding dieulafoy cecal lesion.Figure 2Figure 3.: Hemostasis achieved with three hemostatic clips.

S3454 Dieulafoy Lesion Masquerading as Diverticular Bleeding

INTRODUCTION: Dieulafoy lesion (DL) is an aberrant submucosal artery which protrudes from a small mucosal defect presenting with massive painless gastrointestinal bleeding (GIB) in the form of melena, hematemesis or hematochezia (Hcz), depending on its location. DLs are most commonly found in the proximal stomach within 6 cm of the gastro-esophageal junction along the lesser curvature, however, can occur anywhere along the GI tract to a lesser degree. DLs in the small intestine are rare, mostly seen in the jejunum, with DLs in terminal ileum occurring even rarer. CASE DESCRIPTION/METHODS: A 49-year-old woman with hypertension and history of peptic ulcer disease presented to emergency department complaining of maroon colored stools. She denied epigastric pain, nausea, constipation or weight loss. Her last colonoscopy (CF) was at 48 years of age with finding of “benign” polyps. Patient’s family history was significant for colon cancer in her father. Physical exam was positive for maroon colored stool on rectal exam. Laboratory tests revealed hemoglobin (Hgb) of 9.7 mg/dL, blood urea nitrogen (BUN) of 14 mg/dL and creatinine of 1 mg/dL. Endoscopic evaluation was started with esophagogastroduodenoscopy (EGD), which revealed no source of active or stigmata of recent bleeding. During EGD, patient had a large bloody bowel movement and decision was made to proceed with unprepped CF, which revealed small internal hemorrhoids, pan-diverticulosis and maroon colored blood clots in terminal ileum, which were felt to be secondary to incompetent ileocecal valve. Hcz was thought to be secondary to diverticular bleed, however, over the course of the day patient was noted to have a significant drop in Hgb to 5.7 mg/dL and continued to have Hcz. Blood transfusion was initiated and computed tomography (CT) angiography ordered, which was found to be negative for active bleeding. Repeat CF after bowel prep revealed a 0.3 cm ulcer with visible non-bleeding vessel in the terminal ileum, and was treated with epinephrine injections and two endoclips. Patients remained hemodynamically stable and was ultimately discharged home. DISCUSSION: DLs can cause life threatening hemorrhages and account for 1–2% of overt GIBs. They can be difficult to differentiate from other sources of bleeding, such as diverticular bleeds or bleeding due to arterio-venous malformations. Multidisciplinary approach is necessary for quick diagnosis and proper treatment as multiple endoscopies and imaging studies may be necessary to localize the site of bleeding.Figure 1.: Terminal Ileum filled with blood from first colonoscopy.Figure 2.: 0.3 cm ulcer with visible vessel in terminal Ileum.Figure 3.: Status post injection of epinephrine and placement of 2 endoclips.

Dieulafoy Lesion of Ileum: A Case Report


 
 
 
 Dieulafoy lesion is a rare cause of massive GI bleeding. It’s an abnormal sub-mucosal artery protruding from a minute mucosal defect (≤3 mm). A 31 yearold male presented with complaints of hematochezia. Preliminary investigations failed to locate the exact source of bleed. Enteroscopy suggested distal ileal bleed. At laparotomy, an ulcerated nodular lesion, approximately 0.5 cm was identified in distal ileum. 30 cm of ileum along with mesentery was resected. Histology revealed it to be Dieulafoy lesion. Dieulafoy lesion is uncommon but one of the causes of obscure gastrointestinal bleeding that could result in treacherous and life-threatening gastrointestinal haemorrhage. This lesion is difficult to identify and high index of suspicion is required to make diagnosis. Hence, it should be considered in the differential diagnosis of active GI bleeding. The definitive diagnosis is based only on histopathology.
 
 
 

Abnormal submucosal artery mimicking submucosal tumor in the sigmoid colon

Abnormal submucosal artery mimicking submucosal tumor in the sigmoid colon

EUS-aided diagnosis and treatment of bleeding gastric Dieulafoy's lesion (with video).

Dieulafoy's lesion is an uncommon life-threatening condition, accounting for 1.5% of upper gastrointestinal (GI) bleeding.[1] This is due to tortuous arterioles (1–3 mm) seen in the submucosal layer,[2] also known as “persistent caliber arteries.” Usually, arteries narrow as they branch out toward the mucosa, and submucosal end arteries are normally 0.12–0.2 mm in diameter.[1] A 64-year-old diabetic and hypertensive male patient was being treated for chronic liver disease with portal hypertension. He underwent a transarterial chemoembolization procedure for hepatocellular carcinoma 2 years ago. He had a history of variceal band ligation. He was referred from a nearby general hospital where he presented with three episodes of hematemesis in the past 6 months. Endoscopy showed a vascular malformation (0.5 cm × 0.5 cm) with central ulcer in the fundus, with a small fundal vessel nearby [Figure 1a]. EUS showed a persistent caliber feeding arteriole with a diameter of 1.7 mm, suggestive of Dieulafoy's lesion, with a prominent vein nearby [Figure 2a]. Endoscopic hemoclipping was attempted, but hemostasis could not be attained because of the difficult position of the lesion. An Ovesco clip (OTSC®, Ovesco Endoscopy AG, Germany), which facilitates effective full circumferential tissue closure, including the vascular malformation, was used. Following deployment of the Ovesco clip, the Dieulafoy's lesion oozing was controlled, but there was separate new oozing from the vein nearby, which was possibly caused by one of the prongs of the Ovesco clip injuring the fundal vein. This was managed by injection of 0.5 ml of cyanoacrylate glue. Endoscopy repeated the following day showed the clip in situ with no active ooze [Figure 1b]. EUS after the procedure showed the clip at the Dieulafoy's lesion impeding flow in the artery [Figure 2b and Video 1]. The patient was under our follow-up for nearly 1 year without further episodes of GI bleeding. In our patient, the Ovesco clip was efficient in achieving hemostasis, as its design aids complete circumferential tissue closure including the vessel involved. There are few case reports for Ovesco clip use in Dieulafoy's in the stomach or duodenum.[34] Angiographic embolization and surgical interventions are reserved for cases when endoscopic interventions fail.Figure 1: (a) Endoscopic picture showing 5x5 mm sized vascular malformation with a small central ulcer (yellow arrow) with a small fundal vessel (white arrow) nearby. (b) Endoscopic picture showing Dieulafoy's lesion after OVESCO clipping (yellow arrow)Figure 2: (a) EUS showing a 1.7 mm sized persistent caliber artery in submucosa (pink arrow) with arterial Doppler pattern. (b) EUS showing OVESCO clip in situ (pink arrow) with abrupt cut off of the arteriole. Doppler suggests arterial patternDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

3131 Rectal Dieulafoy's Lesion: A Rare Cause of Massive Lower GI Bleed

INTRODUCTION: Dieulafoy's lesions can be a life-threatening source of gastrointestinal bleeding. While most commonly seen in the stomach, they have been described throughout the GI tract, including the rectum. These lesions consist of a persistent caliber, submucosal artery that can be difficult to identify on endoscopic evaluation. Rectal Dieulafoy's lesions are a rare source of lower GI bleeding that can present with large volume hematochezia requiring prompt management. Two cases of bleeding secondary to a rectal Dieulafoy's lesion are reviewed. CASE DESCRIPTION/METHODS: Case 1: A 94-year-old man with multiple cardiompulmonary comorbidities presented initially for sepsis secondary to osteomyelitis and developed hematochezia during admission. Hgb went from 10.0 g/dL to 7.1 g/dL, but he remained hemodynamically stable and bleeding self-resolved. Colonoscopy was deferred due to patient preference. The patient was readmitted to the hospital 8 days later with continued hematochezia and found to have Hgb 6.3 g/dL. Colonoscopy showed a visible Dieulafoy's lesion that was injected with 2 mL 1:10,000 epinephrine and then treated with 2 hemostatic clips. After intervention, bleeding resolved. Case 2: A 91-year-old man with a history of dementia and COPD was admitted for two days of hematochezia. On admission, he was transiently hypotensive with a SBP in the 50s and a Hgb of 9.4 g/dL with a baseline of 13-14 g/dL. Hgb eventually reached a nadir of 7.4 g/dL. Flexible sigmoidoscopy showed a visible Dieulafoy's lesion. Three hemostatic clips were placed in setting of active oozing with control of bleeding. DISCUSSION: Dieulafoy's lesions were first described in 1884 and are now more commonly described given advances in endoscopy. These lesions account for only 1-2% of GI bleeds, however this number may be underrepresented due to the difficulty of diagnosis. The rectum is involved in only about 2% of cases of Dieulafoy's lesions. The etiology of these lesions is unclear, but likely have some relationship to age, co-morbidities, and NSAID use. Endoscopy is the main method of diagnosis, though EUS, VCE, or angiography are also useful. Hemostasis is usually achieved through thermal therapy, injection with epinephrine, or banding/hemoclip with dual modality being preferred. The cases above represent two examples of a rectal Dieulafoy's lesion, a rare etiology of lower GI bleeding. Management of these bleeds requires prompt evaluation with endoscopy and can be successfully treated via multiple modalities.

2015 Dieulafoy Lesion on the Other Side of the Tract

INTRODUCTION: Dieulafoy lesions involve a large-caliber, tortuous artery in the muscularis mucosa that protrudes due to a submucosal defect with fibrinoid necrosis at the base. The submucosal artery is found to have atypical branching and as a result has a diameter of 1-3 mm, which is 10 times that of a normal mucosal capillary. These lesions can be found throughout the gastrointestinal tract, though they are most frequently found in the stomach, ranging between 61 to 82%. However 10% of all gastrointestinal tract Dieulafoy lesions are found in the colon with 42% of these lesions found in the rectum. CASE DESCRIPTION/METHODS: A 79-year-old male with past medical history significant for prostate cancer, hypertension, gout, degenerative joint disease and alcohol abuse disorder presented with bilateral leg weakness and was admitted to the medical service for alcohol dependency and acute kidney injury. On day 12 of hospitalization, he developed melena with a drop in hemoglobin from 12.0 g/dL at the time of admission to 7.7 g/dL. He was then transferred to the critical care unit and underwent esophagogastroduodenoscopy that revealed angioectatic lesions that bled and were treated with argon photocoagulation. On day 15, he developed hematochezia, which further decreased his hemoglobin to 6.9 g/dL. He became hemodynamically unstable, requiring rapid fluid and blood resuscitation. Emergent CT angiography was concerning for vascular malformation in the rectal wall. Colonoscopy was performed and a stream of pulsatile bleeding without an ulcer or varix, consistent with a Dieulafoy lesion, was seen in the rectum. Epinephrine was applied, the lesion was clipped, and hemostasis was achieved. No repeat episodes of gastrointestinal bleeding were reported afterwards. DISCUSSION: Bleeding from Dieulafoy lesions can cause hemodynamic compromise as noted in this patient. Therefore prompt identification and treatment is warranted. Endoscopy serves as a gold standard for identification. Hemostasis has been achieved with many techniques in case reports including: BICAP cauterization; combined sclerotherapy and electrocoagulation; heater-probe coagulation; and epinephrine injection combined with electrocoagulation. Rebleeding rate ranges from 6 to 28%. Systemic reviews and retrospective analysis suggest that mechanical ligation to achieve hemostasis, especially the use of hemoclips, may be superior to other techniques employed.

2003 Extragastric Dieulafoy’s Lesion: A Rare and Often Missed Cause of Upper Gastrointestinal Bleeding

INTRODUCTION: Dieulafoy’s lesions (DL) are an important, potentially life threatening, cause of gastrointestinal (GI) bleeding. Dieulafoy’s lesions are dilated, aberrant, submucosal arteries that erode overlying GI mucosa in the absence of an underlying ulcer, aneurysm, or intrinsic mural abnormality. They account for approximately 1.5% of acute upper GI bleeding and 70% of these lesions are found within 6 cm of the gastroesophageal junction. Although uncommon, DL have been reported in the duodenum, distal stomach, and esophagus. We present a case describing the discovery and management of an extragastric DL within the duodenum. CASE DESCRIPTION/METHODS: An 83-year-old male with multiple comorbidities, on warfarin therapy, presented to the hospital by instruction of his primary care physician for evaluation of a low hemoglobin (Hgb). He has a history of chronic anemia with regularly monitored Hgb. The patient endorsed 4 days of painless, dark, loose stools. He reported a similar episode to this several years prior and underwent upper and lower endoscopy, which were unrevealing. Capsule endoscopy at that time did show a small bowel arteriovenous malformation, but otherwise unremarkable. On admission, the patient was hemodynamically stable with mild pallor noted on exam. Initial workup revealed Hgb of 6.8 g/dL and an INR of 3.1. Upper endoscopy was performed revealing a single spurting spot of active bleeding in the second part of the duodenum consistent with a DL. The area was successfully treated with epinephrine, coagulation, and hemostatic clips. He remained hospitalized for five days post-procedure for medical optimization. His Hgb remained stable and his warfarin was resumed. DISCUSSION: Dieulafoy’s lesions are a rare cause of upper GI bleeding that should always remain on the differential diagnosis. While gastric DL are well-known, there are few reports describing DL of the duodenum. The scarce nature of their occurrence make these lesions difficult to diagnose. Thorough endoscopic evaluation is usually the first diagnostic test performed for acute upper GI bleeding. Thus, this is the primary modality used for the diagnosis of DL. Initial EGD is diagnostic in only about 70% of cases due to relatively small lesion size, intermittently active bleeding, and lesion location. This case represents a patient with acute on chronic anemia that had previously undergone a thorough investigation with few answers. Serial Hgb monitoring and follow-up endoscopy led to the discovery and treatment of his duodenal DL.

A CASE OF DUODENAL DIEULAFOY’S LESION

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Dieulafoy’s lesion is a rare cause of gastrointestinal (GI) hemorrhage, predominantly occurring in the upper part of the stomach, along the gastric lesser curve; extra-gastric lesions are uncommon. We present a case of a massive GI bleed due to Dieulafoy’s lesion in the duodenum. CASE PRESENTATION: 51 y/o female that presented to ED from home with a 2-day history of right-sided abdominal pain and bloody diarrhea. Pain was associated with multiple episodes of dark red/black diarrhea, nausea and one episode of coffee ground emesis subjective fevers and chills. Of note, she had just finished a 10 day course of PO Augmentin that was prescribed for a dog bite. She has a PMH of neuroendocrine tumors, lymphoma s/p chemotherapy and uterine tumor s/p hysterectomy. Physical exam was positive for abdominal tenderness in the right upper and lower quadrants. On admission, Hgb was 12.5 g/dL, WBC 20.2, lactate 3.5 with normal LFTs and lipase. Patient was admitted to the general medical floor for evaluation of bloody diarrhea and to rule out C. difficile colitis. A CT scan of the abdomen without contrast was done which showed the third part of the duodenum to be compressed by the super mesenteric artery (SMA) suggestive of SMA syndrome; surgery was consulted with no intervention warranted. Within 24 hours of admission, patient continued to complain of severe abdominal pain, bloody diarrhea and sudden dizziness; she was noted to be hypotensive with BP 90/60, tachycardic and Hgb had dropped to 7.9 g/dL. Crystalloids were administered without improvement in BP. She was transfused 1 unit of pRBCs, started on a Protonix drip and transferred to MICU. She received a total of 3U of pRBCs prior to stabilization of vital signs and hemoglobin. An EGD was done, which revealed active bleeding from a spurting vessel in the duodenal bulb; epinephrine was injected and 2 clips were placed with successful hemostasis. Patient’s Hgb remained stable after the procedure and she was discharged home 3 days later without sequelae. DISCUSSION: Dieulafoy’s lesion is a dilated, aberrant submucosal artery which doesn’t undergo normal branching within the wall of the stomach and erodes the mucosa in the absence of a primary ulcer. They are primarily found in the upper part of the stomach, within 6 cm of GE junction, particularly in the lesser curvature; extragastric incidence in esophagus, duodenum and colon is rare. It is the cause of less than 5% of all GI bleeds in adults, and occurs twice as often in men than women. Condition is usually diagnosed via EGD, however diagnosis can oft be difficult due to size and obscure location. Etiology is unknown. CONCLUSIONS: Although it is a rare condition, clinicians should maintain a high index of suspicion for this disease in the etiological evaluation of patients presenting with gastrointestinal hemorrhage, principally as it can cause massive and life threatening bleeding. Reference #1: Nojkov B, Cappell MS. Gastrointestinal bleeding from Dieulafoy's lesion: Clinical presentation, endoscopic findings, and endoscopic therapy. World J Gastrointest Endosc. 2015;7(4):295-307 Reference #2: Lee, Y., Walmsley, R. S., Leong, R. W., & Sung, J. J. (2003). Dieulafoy's Lesion. Gastrointestinal Endoscopy, 236-24 Reference #3: Isik A, Alimoglu O, Okan I, Bas G, Turgut H, Sahin M. Dieulafoy lesion in the stomach. Case Rep Gastroenterol. 2008;2(3):469-73 DISCLOSURES: No relevant relationships by Nayma Casamayor, source=Web Response No relevant relationships by Yelenis Fuertes Yanes, source=Web Response No relevant relationships by Michelle Hernandez Guzman, source=Web Response